Bright School - Mini Medical Form

Bright School - Mini Medical Form
All students are required to submit completed health forms, including an updated physical form and full immunization record (including Tuberculosis screening with testing if applicable), which demonstrates proof of required immunizations and is signed by the student's health care provider. Parents/Guardians are expected to access all of the medical forms below in the student's SchoolAdmin portal, have them completely fill them out, and upload them back into their portals in the appropriate tabs.

No student will be permitted to move onto campus or participate in any school activities/sports until all of the required forms are uploaded into SchoolAdmin.
Student Health Information

To be filled out by parent/guardian.
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Any Health Concerns*

YesNo
Prior Surgery*

YesNo
Hospitalizations*

YesNo
Allergies to Medicine*

YesNo
Allergies to Food/Latex/Bee’s etc.*

YesNo
Ever treated for severe allergic reaction or anaphylaxis*

YesNo
Any daily medications (prescription and non-prescription)*

YesNo
Glasses or Contacts*

YesNo
Hearing Problems*

YesNo
Speech Problems*

YesNo
Dental Problems (braces, caps, bridges etc.)*

YesNo
Bleeding Issues/Anemia*

YesNo
Heart Problems*

YesNo
Religious/Cultural Beliefs*

YesNo
Family History of adverse reaction to anesthesia*

YesNo
Artificial implants or metal in the body*

YesNo
Breathing problems or chronic cough*

YesNo
Smoker*

YesNo
Asthma History*

YesNo
Any Problems Running*

YesNo
Muscle or joint injuries*

YesNo
Broken bones /dislocations*

YesNo
Neck or back injuries*

YesNo
Concussion treatment*

YesNo
Ever Fainted or blacked out*

YesNo
Migraines or chronic headaches*

YesNo
Any behavioral issues*

YesNo
Anxiety, depression or mental illness*

YesNo
ADD / ADHD*

YesNo
Psychiatric treatment or counseling*

YesNo
Any family history of unexplained sudden death (prior to age 50)*

YesNo
Any medical treatment/hospitalizations in the past year*

YesNo
Does your child take any prescription or non-prescription medications*

YesNo
Please explain all “YES” answers here. For injuries/surgeries please include year or age of child at time:*
I give permission for the release and exchange of information on this form between PSA Health Center and health care providers for confidential use in meeting my child’s health and educational needs.
Signature of Parent/Guardian*

Clear
Health Insurance
All students are required to have health insurance coverage and provide current copies of insurance cards. International students who will require Health Insurance are to contact the Admissions Department as soon as possible. Any medical expenses not covered by a student’s insurance plan, including co-payments, provider charges, prescription/medication expenses, immunizations, lab fees, and/or medical supplies, and out-of-network costs, must be billed directly to the parent at the home address. In some cases, students may be required to pay co-pay, medication costs, and any other medical expenses directly to the provider at the time of service.

I have read all of the above information and understand that it is my responsibility to provide all necessary documents PRIOR to my child arriving on campus in August.
Signature of Parent/Guardian*

Clear
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Bright School - Mini Medical Form

Student Health Information

Health Insurance